Frequently Asked Questions

Care away from home

Plan for a healthy trip and get medical care if you need it. You have coverage for urgent care and emergency care while traveling outside of our service area. However, know the difference. If you go to the emergency room and it's not a true emergency, you may be responsible for the entire cost of the visit.

The ER and urgent care aren’t your only options.

You also have 24/7 access to NowClinic® Virtual Visits for common care needs (not for urgent or emergency care). This service lets you connect with a provider from a computer or mobile device. No appointment necessary. Visit NowClinic.com or download the app.

Access your health plan information on the go. Sign in to the online member center to view your benefit information, claims history, pharmacy information and more.

If you have any questions, please call Member Services toll-free at 1-800-777-1840, TTY 711, Monday through Friday, 8 a.m. to 5 p.m.

Most providers will bill Health Plan of Nevada directly.

Before you submit a non-plan provider claim form to us, find out if it's necessary. Many providers will submit claims even if they're not in our network. This is why it's important to show your health plan ID card at each appointment.

If you're asked to submit the claim, please complete Section 1 of the non-plan provider claim form. Your provider must fill out Section 2.

In addition, please include copies of any applicable itemized bills and/or receipts from your provider.

The itemized bill must include the following information:

• Name, address, and tax ID number
• Date of service
• Diagnosis
• Description of services and/or standardized codes rendered, and itemized charges for each service

Items that will not be accepted for reimbursement include, but are not limited to, billing statements indicating balance due or credit card receipts.

Completed form with copies of corresponding bills and/or receipts should be sent to:

Health Plan of Nevada
Claims Department
P.O. Box 15645
Las Vegas, NV 89114-5645

Your doctor will help coordinate your care if you should ever need to be admitted to a hospital on a non-emergency basis.

Our team will help monitor your care by performing initial and ongoing reviews. This is to make sure the health care services you receive are appropriate, provided in the right setting, and medically necessary. If you’re admitted to a hospital outside of our service area, we may review your medical records to evaluate the appropriateness of the medical care, services, treatments, and procedures you received.

Depending on your situation, we’ll arrange for any ongoing medically necessary care, services, and equipment you need after leaving the hospital. This may include in-home care or transferring you to another facility.

If you have any questions, call toll-free 1-800-777-1840, TTY 711, Monday through Friday, 8 a.m. to 5 p.m.

If you're an individual plan member, you can pay your premium online, by phone or by mail. Your premium, the amount you pay for your health insurance plan, is due on the first day of each month. Once we receive your payment, it will show on our system within 2-3 business days.

Prior authorization is necessary to ensure benefit payment

Your provider may prescribe a health care service, treatment, equipment or medication which requires review and approval. This process is called prior authorization, and the goal is to ensure you receive the most appropriate, medically necessary care.

All requests requiring a medical or clinical decision are reviewed by a licensed physician or under the supervision of one. Furthermore, only a physician may deny a request. To learn more, please consult your plan documents or sign in to the online member center.

You or your provider may file an appeal if coverage is denied. To appeal a decision, mail a written request within 180 days from the date of the denial to: Health Plan of Nevada, Member Services, P.O. Box 15645, Las Vegas, NV 89114-5645

For Applied Behavioral Analysis (ABA) therapy authorization requests, your ABA provider should complete and submit this form.

Get a referral.

A referral is a recommendation from your primary care provider (PCP) to receive a service or care from another doctor or facility.

Your PCP may refer you by:

• Signing in to our online provider center and filling out an online referral form
• Completing a hard copy of the referral form

To use your Tier 1 HMO benefit option, you'll need a referral from your PCP to see a specialist.

Sign in to the online member center and select the Change Primary Care Physician button. Enter the book code for your preferred doctor, effective date and reason for the change. Then select Submit.

Be sure to enter the doctor’s entire code including the dash (-). If you don’t know his/her code, search the list of available physicians by starting here.

You can also call Member Services toll-free at 1-800-962-8074, TTY 711, or use our concierge, or personalized, services. Stop by our offices and a member of our team would be happy to assist you.

Our offices are located at:
2720 N. Tenaya Way, Suite 102
Las Vegas, NV 89128

Keep your information up-to-date.

Sign in to the online member center and select My Account on the top navigation bar.

You will be able to:

• Change your account password
• Update your profile
• Change your address
• Choose your communication preferences
• View and print your health plan ID card
• See who has accessed your health record
• Review a list of communications recently sent to you

If you’re a Southwest Medical patient, you may opt-in to review your electronic medical records. Simply sign in to your account, select My Account and then select Health Record Authorization.

If you or one of your dependents experience a qualifying life event, which affects your eligibility or your dependent's eligibility to receive health benefits under your health plan, it's your responsibility to provide written notice within 31 days of the event or change.

If you have an On Exchange Individual plan, please contact NevadaHealthLink.com. If you have an Off Exchange Individual plan, simply complete a membership change form and mail it to: Health Plan of Nevada, P.O. Box 15645, Las Vegas, NV 89114-5645.

Group health plan members (those who receive health insurance coverage through their employer) should fill out a change form request and give it to their employer. The employer will submit it to the company's Group Services representative.

Common life/family events may include but are not limited to:

• Marriage or commencement of domestic partnership
• Divorce, legal separation or termination of domestic partnership
• Addition of a child via birth or adoption
• Death of the health plan member or his/her dependent(s)
• Change of home address outside the plan’s service area

Common employment status changes may include but are not limited to:

• Employee becomes newly eligible to receive coverage
• Employee becomes ineligible to receive coverage or loses employment
• Spouse/domestic partner obtains health benefits in another group health plan
• Spouse/domestic partner loses employment or coverage in another group health plan

If proper notice is not provided, which would have resulted in termination of coverage, Health Plan of Nevada shall have the right to terminate coverage.